Application for Extended Leave Beyond Three Days Please complete the form to explain your son's absence. Student First Name:*Student Last Name:*Year Group*Year 7Year 8Year 9Year 10Year 11Year 12Homeroom5 Character code eg. 07SURA, 12RICBParent/Carer First Name:*Parent/Carer Surname*Parent/Carer Email* Age*Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of exemption from:* Date Format: DD slash MM slash YYYY Date of exemption to:* Date Format: DD slash MM slash YYYY Number of School days*Reason for application of exemption:*Study at another Institute for selected timeHoliday outside of nominated School Vacation timeDirection under Section 42D of the Public Health Act 1991Employment in entertainment industry/participation in elite sporting event for short periods of time i.e. for one or two days, and at short noticeOther Exceptional CircumstanceExceptional domestic circumstancesPlease provide more detail about the reason for the application for exemption here:*Support Documentation (eg. Doctor's Certificate, Appointment, letter etc.) Drop files here or Parent DeclarationAs the parent of the above mentioned student, I hereby apply for a Certificate of Exemption from attendance at school, under the Education Act 1990. I understand that if the exemption is granted: - I am responsible for his/her supervision during the period of exemption - the exemption is limited to the period indicated - the exemption is subject to the conditions listed on the Certificate of Exemption - the exemption may be cancelled at any time. I declare the information provided in this application for a certificate of exemption is to the best of my knowledge and belief accurate and complete. I recognise that should statements in this application later prove to be false or misleading any decision made as a result of this application may be reversed. I further recognise that a failure to comply with any condition set out in the exemption may result in the exemption being revoked. Note - long term exemptionsWhere the reason for application for exemption includes long term travel arrangements of more than 20 school days, copies of travel documentation is to be included with the application.Prior/Current Exemptions (if applicable)The following ONLY applies to students who have previously applied for leave or have a current leave application in place.Date of prior/current exemption from Date Format: MM slash DD slash YYYY Date of prior/current exemption to: Date Format: MM slash DD slash YYYY Number of school days:Attach certificate of exemption Drop files here or EmailThis field is for validation purposes and should be left unchanged.